• Utilization Management Nurse

    Adecco US, Inc. (Houston, TX)


    Adecco Healthcare & Life Sciences is assisting a client hire a Utilization Management Nurse in Houston, TX! This role is hybrid with a mix of work from home and in office days. Please read below and apply with an updated resume for consideration:

     

    **Type:** Full time – direct hire with client!

    **Schedule:** Monday through Friday, 8am to 5pm

    **Pay:** $85,00 to $110,000 yearly

    Responsibilities of the Utilization Management Nurse:

    • Responsible for the follow-up through for the targeted case management of patients and manages the physician network.

    • Reviewing patient history and medical records, including health risk assessment and previous care plans.

    • Contacting members to discuss their health care needs and assist with care plan development.

    • Development of Individualized Care Plan (ICP)

    • Updates to Individual Care Plan (ICP) when patient’s condition changes or patient has a transition of care.

    • Participation in Interdisciplinary Care Team (ICT) meeting member, social worker, PCP, health plan, and other care provider.

    • Implement departmental policy and procedures to assure an effective UM and Case Management program

    • Reviews and evaluates MIS generated UM and Case Management reports

    • Reviews authorizations and referral requests that do not meet the explicit criteria set for the UM Coordinators

    • Identifies those members who would best qualify for Case Management and institutes a care management plan

    • Provides concurrent review on members who are hospitalized at all levels of care (if delegated by the health plans; notifies health plans if not delegated by the health plans).

    • Assists with the submission of the reports for contracted health plans, the Board of Directors and regulatory agencies as required

    Qualifications for the Utilization Management Nurse:

    • Bachelors’ degree in nursing

    • Current, unrestricted RN License in Texas

    • 2 to 5 years of experience in a managed care setting

    • Knowledge of the states federally funded healthcare programs: Medicare, Medicaid, and the state.

    • Knowledge of network development strategies and provider relations experience

    • Knowledge of authorizations, claims, credentialing, RAF, HEDIS, STAR ratings

    **Pay Details:** $85,000.00 to $110,000.00 per year

     

    Benefit offerings available for our associates include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and a 401K plan. Our benefit offerings provide employees the flexibility to choose the type of coverage that meets their individual needs. In addition, our associates may be eligible for paid leave including Paid Sick Leave or any other paid leave required by Federal, State, or local law, as well as Holiday pay where applicable.

     

    Equal Opportunity Employer/Veterans/Disabled

     

    To read our Candidate Privacy Information Statement, which explains how we will use your information, please navigate to https://www.adecco.com/en-us/candidate-privacy

    The Company will consider qualified applicants with arrest and conviction records in accordance with federal, state, and local laws and/or security clearance requirements, including, as applicable:

    + The California Fair Chance Act

    + Los Angeles City Fair Chance Ordinance

    + Los Angeles County Fair Chance Ordinance for Employers

    + San Francisco Fair Chance Ordinance